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Patient beliefs regarding benefits of coronary revascularization

Patient beliefs regarding benefits of coronary revascularization. Jeff Whittle, MD, MPH Staff Physician Clement J. Zablocki VA Medical Center. Background. Doctor Patient communication important understudied Coronary revascularization common procedure discrete decision

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Patient beliefs regarding benefits of coronary revascularization

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  1. Patient beliefs regarding benefits of coronary revascularization Jeff Whittle, MD, MPH Staff Physician Clement J. Zablocki VA Medical Center

  2. Background • Doctor Patient communication • important • understudied • Coronary revascularization • common procedure • discrete decision • clinical factors well studied

  3. Objectives of study To determine whether patients clearly grasp the benefits and risks of coronary revascularization. To identify predictors of doctor - patient miscommunication

  4. Objectives of presentation • Ingratiate myself to Mary Ann Gilligan • Describe a rich dataset that has been underutilized • Get objective feedback/input regarding: • How interesting the results are • Biggest methodologic concerns • Relevant literature re: MD-Pt communication

  5. Methods - Study population • American Heart Association funded study • racial differences in cardiac procedure use • patient preferences • Four tertiary care centers • Coronary angiography • all consenting patients as logistics allowed • emphasized African American recruitment

  6. Methods – patient surveys - 1 • Enrolled patients in a variety of places • Pre-cath holding area • Inpatients approached evening prior to cath • Trained research assistants • Racially diverse • Face to face enrollment/interview

  7. Methods – patient surveys - 2 • Pre-catheterization • demographics/health status • reason for catheterization • Post - decision to undergo revascularization • most important considerations • expected benefits - survival, symptoms, etc. • estimated risks • strength of physician recommendation

  8. Methods – physician surveys • Post-catheterization • Benefits of the procedure for this patient • symptom control • prevent infarction or reinfarction • decrease mortality • Risk of adverse events • How strongly recommended • Self-complete or face-to-face

  9. Methods: Analysis • Open-ended question • developed classification • two people reviewed all responses • consensus used when disagreement • Agreement • descriptive statistics • chi-square for significance testing

  10. Results – Study Population • Patient enrollment • 1653 enrolled • 1565 completed post - cath survey • 660 reported they were offered procedure • 637 completed pre and post-cath surveys • Attending survey • 1489 responses (note some help on clean cors) • 546 in this cohort

  11. Results: Study population

  12. Results: Study population

  13. Expected benefit versus what heard Sym1 and sur1 treat unknown/unsure as missing. Sym2 and sur2 treats unknown/unsure as not expecting benefit. All p < 0.001

  14. Expected benefit versus what MD thinks Sym1 and sur1 treat unknown/unsure as missing. Sym2 and sur2 treats unknown/unsure as not expecting benefit. P> 0.05 for all

  15. Expected benefit of PCI vs MD report * Sym1 and sur1 treat unknown/unsure as missing. Sym2 and sur2 treats unknown/unsure as not expecting benefit. * P< 0.05

  16. Expected benefit of CABG vs MD report Sym1 and sur1 treat unknown/unsure as missing. Sym2 and sur2 treats unknown/unsure as not expecting benefit. P< 0.05 for sym measures

  17. MD patient agreement: Subgroups Agreement not different from chance

  18. Univariate predictors of agreement

  19. Predictors of MD-patient agreement • Univariate predictors for survival • age < 60; more education; University site • survival mentioned as important consideration • Univariate predictors for symptoms • PTCA as procedure; black race • refusal/deferral of procedure

  20. Results Summary • Patients expect benefits of revascularization that they did not hear from the physician offering the procedure • This is unrelated to demographics

  21. Conclusions • Doctor patient communication does not achieve the goal of an informed patient • In particular, improved survival is an expectation that is oftentimes held in error

  22. Limitations • External validity limited by the setting • Very few of the patients who were interviewed declined the procedure • Many patients interviewed post - procedure • No qualitative data regarding the reasons for discrepancies

  23. Implications • If one desires an informed decision about procedures, more efforts need to be made to instruct patients • more physician time • personalized shared decision making tools • Future research needs to address clinical consequences of, and reasons for, misunderstanding

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